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1.2 The history and development of public health in developed countries

1.2 The history and development of public health in developed countries
Oxford Textbook of Public Health

The history and development of public health in developed countries
Christopher Hamlin

Themes and problems in the history of public health
The public health of epidemic crisis: reaction
The public health of communal life: police
The public health of human potential
The age of liberalism: health in the name of the people 1790 to 1880
1880 to 1970: the golden age of public health?
The return of liberalism, 1970 to the present day: lifestyle, environment, and welfare
Chapter References

Much more than is usually realized, public health is both a central and a problematic element of the history of the developed world—here conceived as Europe and the ‘Neo Europes’, i.e. the set of nations in broad latitude bands in the northern and southern hemispheres in which European institutions and biota have been particularly successful (Crosby 1986). It could be argued that a history of these regions in the last three centuries has broadly been a history of their health. It is in health terms that our lives are most profoundly different from those of our ancestors. We live longer; fewer parents experience the death of their young children and fewer adults experience the gradual ‘consumption’ of pulmonary tuberculosis; affluence and transportation mean most of us are no longer subject to periodic famines, and much less subject to epidemics of deadly infectious diseases, though we are less confident about that than we were two decades ago. Nor are most of us wracked with chronic pain, with abcesses, or induced deformities; most of us do not see life as a continuously painful experience and death as a merciful release, a view that is found fairly commonly in books of theology from three centuries ago (Browne 1964).Our health is adversely affected by aspects of the world we have built and the ways we choose to live individually and communally. A good deal is known about how to prevent those effects even if we do not always do so. Nonetheless, an expectation of health, and a preoccupation with it, are hallmarks of modernity. The freedom of action that ideally characterizes the lives of individuals in the developed world is predicated on health; so much of the agenda of development concerns health, that this transformation in health has some claim as one of the monumental changes in human history. It might be argued that economic and political progress are subordinate to securing health—they are means; health, which surely translates into life, liberty, and the pursuit of happiness, is the end.
If health is what we are all striving for, why is public health so invisible a part of our past? Until recently historians have been unconscionably negligent in investigating its history. Few general texts give it much attention (but see McNeill 1976); vast gaps in our empirical knowledge remain, and there is little good comparative work (but see Baldwin 1999; Porter 1999). Compared with the grand dramas of history, public health can seem a marginal function of modern society, representing little diversity, and nothing controversial. After all, we provide medicine, collect and evaluate demographic data, test water, and keep cities clean in roughly similar ways, according to the conventions of science, technology, and public administration that developed mainly in the nineteenth century. This view partly reflects a distortion of the history of public health by the modern professions and institutions of public health, which have often found it prudent to reduce the significance of the fact that they are necessarily political, even if their business is politics by medical means.
Public health is treated more broadly in this chapter, by examining actions taken in the name of a public to protect or improve the health of the public in general. Even that story is complicated by ambiguities—conceptual, causal, and definitional. Questions of what ‘health’ is, of what we mean by ‘public’, and of what we understand to be the proper domain of ‘public health’ are now, and have always been, contested matters. To define public health as that part of health that is the responsibility of the state does not help us to define these terms as what constitutes the state varies in time and place. However broadly or narrowly we define ‘health’, it will probably be admitted that many things that the public does will affect the public’s health. Hence a central issue will be the enigmatic relationship between that universal goal, the health of the public, and public health—as profession, science, component of public administration, and vision (Rosen 1958; Fee 1993; Porter 1999). Within that framework there will be more diversity, contingency, complexity, and controversy in its history than is usually apparent. Ultimately, however, there can be no single historical narrative. A history of public health is necessarily part of an ongoing conversation about a systematic endeavour that is both rational and moral. Inevitably the story we tell will depend on what public health is conceived to be, yet our notions of public health will themselves be a product of the evolution of the professions and institutions we have inherited, and of the myths, memories, and sensibilities that sustain them.
Themes and problems in the history of public health
It will help at the outset to recognize several of the most troublesome issues that face any historian of public health. Amongst these are the following.
The units of public health: states and publics

The public and the state. ‘State’ and ‘public’ are not always interchangeable terms. The state, concerned with population, may arrive at different health-related policies from a public sphere of groups of citizens, carrying out a rational and critical dialogue amongst equals.

The diversity of states. Even when there arose widely accepted reasons of state and agendas of state responsibility, not every state was in the position to act on them. The focus of public health was quite often at the level of local states, whose responsibility and jurisdiction were often unclear or overlapping. However, the state itself became an artificial unit for addressing global problems, and those beyond the merely human.

Goals of the state. While health is now thought of in terms of the biological autonomy of individuals, that has rarely, and only recently, been the goal of programmes of public health. Health has meant a good supply of labour or of soldiers, control of excess population, protection of élites, enhancement of the genetic stock of a population, or environmental stability.
The condition that is truly health

The definition of health. The combating of epidemic infectious diseases has often seemed the core of public health. When we go beyond these diseases, questions arise of what level and kind of physical and mental well being the state should guarantee or require of its citizens, and of the status of health as a source of imperatives in competition with other imperatives such as the market, the environment, or individual liberty. What sort of normality will a society insist upon?

The problem of causation of disease. In a broad sense, diseases have many causes—personal, social, cultural, political, and economic, as well as biological. Amongst the multiple antecedents that converge in the production of epidemic or endemic disease, there are numerous opportunities to intervene. Notions of rights that must be respected, or of political or technical practicality, narrow that list. Discussion of cause has often included notions of responsibility or preventability—of where in a social system there is flexibility, of who or what must change to prevent disease.

Equality and rights—race, class, gender. The idea of ‘health for all’ disguises the fact that the interests of the public have not always been the interests of all of its members. Public health actions have often reflected, and sometimes exacerbated, a view of the world in which some groups were seen primarily as a threat to others. Often views of the standards of health that were matters of state differed for different groups: key divisions were by sex, by age (infants, working adults, and the aged all had a different status), by wealth, and by race, religion, or historical heritage (indigenous people had a different status from colonial rulers). Whether the public’s response to disease was to advise, aid, or condemn, or to imprison, banish, or kill, reflected the allocation of rights and the distribution of power more than the status of the biological threat.
The health that is truly public

Health and public health. Most modern states have in principle distinguished aspects of health that are the business of the public from those that are for the individual to pursue in the medical marketplace, although the borders have been drawn in many different ways.

Medical and non-medical public health. Whilst public health has evolved into a subdivision of medicine with minimal and subordinate inclusion of the ancillary disciplines of engineering and the social sciences, the fact that health has been improved by many non-medical factors—economic prosperity, town planning, architecture, religious and humanitarian charity, the power of organized labour, and even broader political changes resulting in the greater availability of political or economic rights—suggests that any comprehensive account of improved health must include non-medical factors.

Health as authority. Given the amorphous nature of the concept of health and its status as the supreme good of human existence, it has been attractive as an imperative for political action. If other ‘reasons of state’ carry more immediacy, public health has better claim to the moral high ground because it is seen to be universal and apolitical, exactly the qualities that make it attractive to act politically in the name of health.
These questions are too many to address individually in this chapter, but they inform what follows. The history of public health in the developed world can be conceived in terms of three relatively distinct missions: public health as reaction to epidemics, as a form of police, and as a means of betterment. Public health was first reactive. Faced with the threat of an epidemic, European states closed borders and ports, instituted fumigation, shut down piggeries, and isolated victims. The second is public health as police. It is probably the case that wherever humans live in communities customs arise for the regulation of behaviour and the maintenance of the communal environment. Gradually much of the enforcement of these community standards became medical. The control of food adulteration or prostitution, of the indigent and the transient, or concern over dung or smoke overlapped with the control of epidemics, but went well beyond it, and occurred in normal as well as in epidemic times. Last to arise was public health as a proactive political vision for the improvement of the health of all. Even into the nineteenth century the view was widespread that remarkably high urban or infant death rates were inevitable. A proactive public health involved a determination that normal conditions of health, if they could be improved, were not acceptable conditions of health. That this sensibility changed was due partly to technical achievements, such as smallpox inoculation and later vaccination, and to better demographic information, due also to a more optimistic view of the possibility of human progress. Such visions sustained the building of comprehensive urban water and sewerage systems before there was wide acceptance that these needed to be universal features of cities; such visions have periodically led public health to venture beyond recognizably medical bounds, to recognize, for example, nuclear warfare or gun violence as public health problems.
The public health of epidemic crisis: reaction
Regardless of their virulence and pervasiveness, epidemic (and even more so, endemic diseases) do not necessarily warrant comment or action—they may simply be acknowledged as part of life. For a public to decide to fight an epidemic it must believe it can do something to mitigate it. A belief in the possibility of effective action is a prerequisite for public health; one of the most intriguing problems in its history is the emergence of that belief. It does not coincide with the replacement of supernatural by natural explanations of disease causation. ‘Will-of-God’ explanations of disease have sometimes incited public action, but on other occasions implied abject resignation. Similarly, naturalistic explanations, attributing epidemics to a mysterious element in the atmosphere or, as in the case of classical conceptions of smallpox, to a normal process of fermentation in the growing body, have on some occasions been taken as proof that we can do nothing beyond giving supportive care and on other occasions sanctioned preventive public action. In each case assessments of technical and political practicality are mixed with assessments of propriety—is taking such action part of our cultural destiny?
These issues are already evident in the first European account of a widely fatal epidemic, the unidentified plague that struck Athens in 430 BC. Athenians both recognized contagion and acknowledged a duty to aid the afflicted, Thucydides informs us, but these recognitions did not translate into expectations of prevention, mitigation, or escape (Thucydides 1950; Longrigg 1992). Few fled; on the contrary, the epidemic was exacerbated by an influx from the countryside. While it was appreciated that those who survived the disease were unlikely to take it again, and some hoped it would bring permanent immunity from all afflictions, the main response was to accept one’s fate. The disease was attributed to seasons, as well as to gods, and said to have been prophesied. Such resignation would be central in the moral philosophies of the Roman world, Stoicism and Epicureanism, both of which taught one to accept what was fated or necessary (Veyne 1987). Later writers in the Christian world attributed the failure of Islam to take active steps against plague to such an outlook. While classical Islamic doctors developed a science of hygiene to a remarkable degree, it did not follow that one should apply that knowledge in an epidemic: if plague came that was Allah’s will. To fight it would be futile and impious; one’s duty was to trust (Dols 1977; Conrad 1992).
In contrast, the response to epidemic disease in the medieval Christian Latin countries was activist. One could prevent disease from taking hold in a community, or extinguish it if it did, or at least avoid it personally. This activism had many targets, reflective of the syncretism of medieval Latin culture. In the Old and New Testaments alone, disease had a multiplicity of conflicting significations. It represented the dispensation of God to an individual, perhaps as punishment or a test. To act against disease by intervening to help others stricken by a dangerous epidemic was an act of devotion. If one died in such a situation that was a sign of grace; if one did not die, and helped to save others, that was equally a sign of grace. The laws of hygiene in the Pentateuch permitted a naturalistic interpretation of disease. Unclean acts or other transgressions, like failing to isolate lepers from society, generated the retribution of disease, perhaps through God’s appointed secondary or natural causes. Disease might even be naturally communicative; in such a case, communal decisions to maintain the levitical laws were means not only of acting against potential epidemics but of maintaining the police of the community and perhaps of augmenting its welfare (Douglass 1966; Winslow 1980; Amundsen and Ferngren 1986; Dorff 1986). Such views would become widespread amongst nineteenth-century sanitarians.
The two diseases that did spur medieval Europeans to comment and react were leprosy and the plague. Whilst it is difficult to assess how much leprosy there was in medieval Europe, the common view is that there was a vast over-reaction, in terms of both investment in institutions to house victims of the disease—there were said to be several thousand leprosaria—and of detecting and isolating cases to prevent transmission of the disease. In keeping with the prominence of leprosy in the Bible, the professionals who diagnosed it were churchmen, not medical men. The diagnosis was a loose one; it might be based on skin blemishes alone. Often it involved an accusation. It led to the expulsion of the victim from ecclesiastical and civil society, symbolized in a ceremony resembling a funeral. Subsequently, no one was to touch or come near the leper or to touch what the leper touched. The theory of contagion provided the rationale for such action, but Skisnes has argued that the clinical characteristics of the disease itself—for example, its slow development, the visible disfigurement it produced—triggered such a reaction (Skisnes 1973; Brody 1974; Richards 1977; Carmichael 1997). Even if leprosy precautions did embody empirical knowledge of contagion, it, like most other diseases, belonged to the sphere of providence. While leprosy was sometimes seen as a punishment of sin, it might also reflect grace: God’s singling out of an individual to bear a particular burden of suffering.
The prototypical institutional responses to epidemic disease, however, were those that arose in response to plague. The first wave of plague, the Black Death, spread across Europe from 1347 to 1351, and thereafter the disease returned to most areas about once every two decades for the next three centuries. This was a catastrophic disease, with case-fatality rates ranging from 30 to nearly 100 per cent depending on the strain of plague, the means of transmission, and the immunological state of the population. Plague and accompanying diseases reduced the European population by roughly a third in the fourteenth century and were responsible for only a very slow population growth during the following two centuries. As with leprosy, the aetiology of plague and the associated means of prevention and mitigation of the disease were conceived in terms of divine will and natural process, though even more clearly than with leprosy the distinction is misleading: Nature, whether in the courses of the stars, in meteorological phenomena, or in the process of contagion, was God’s instrument (Nohl 1926; Ziegler 1969).
It is clear that in many communities the coming of plague was unacceptable. It could not be reconciled with the usual course of events, but indicated some fundamental violation of the cosmos, of an order which included human society. Boccaccio, whose Decameron is a document of the Black Death, testifies to one form of activism—a discarding of social convention and religious duty, a devil-may-care indulgence in the present founded in the recognition that life was short and the future uncertain. Those who could often fled plague-ridden places. Others, taking the view that the plague reflected God’s just anger with hopelessly corrupt civil and ecclesiastical authority, saw a clear need to take charge of matters temporal and spiritual, to cleanse themselves, the state, and the church. Righteousness would end the plague. Thus the plague precipitated a social crisis, as would epidemics of other diseases in subsequent centuries. Beyond the massive disruption caused by high mortality and morbidity and an interruption of commerce and industry, the loss of faith in the conventions and institutions of society was a critical blow. Why respect property or family or communal obligations, pay taxes, invest money, or tolerate rivals and others? Latent tensions within society had an excuse to become active.
When people acted precipitately and independently, civil and ecclesiastical institutions were threatened, and it is in their responses that we clearly see the emergence of public health as a form of public authority. For a state, to act in a crisis was to keep the state going; one maintained authority by acting authoritatively. If some state actions were rational in terms of naturalistic aspects of theories of the plague, the viability of civic authority itself was probably more crucial than any lives they might save.
All these issues are evident in the manifold responses to plague from the mid-fourteenth to the early eighteenth century. Particularly in Germany, the response to the Black Death was to challenge civil and ecclesiastical authority. In 1349, lay flagellant groups paraded from town to town, giving public penitential performances to end the plague. While they were usually well received, and while their practices were not unorthodox, they did draw attention to what the Church had failed to do, and Pope Clement VI condemned the movement. But the state response to such actions was not uniform, for medieval and early states were not monoliths, but fragile alliances of multiple levels and kinds of authority, existing in continual tension with one another. In Basel, the majority Christian population blamed the plague on Jews—either it came by direct divine action because Jews had been allowed to live in the town, or through a natural agent with which the Jews had presumably poisoned the town’s water. The town’s Jews were rounded up, sequestered on an island, and burned. Here it was a local state, the town council, that took the action. Its credibility was at stake; it needed to be seen to act boldly to secure an end to the epidemic; its action built on pre-existing antisemitism. But to the central state, the Holy Roman Empire, such actions against one group of its subjects verged on anarchy. Emperor Charles IV condemned the persecution and asserted on the basis of medical and religious authority that the Jews were not responsible for the plague (Ziegler 1969).
In contrast, the approaches to plague prevention and control developed in the next two centuries in the Italian city states were humane, focused mainly on naturalistic intervention, and probably relatively successful. Plague control measures emerged out of a tradition of close municipal management, and in a cosmopolitan intellectual environment. Italy, after all, was the main European centre for receiving Galenic and Islamic medical knowledge. Included were concepts of hygiene, disease causation, and the purifying of enclosed spaces. The preventive measures taken in Italian city states were eclectic. They included the development of the 40-day hold on ships or other traffic coming from potentially infected places (the quarantine), the isolation of victims (and families of victims), and numerous means of purifying the air and/or destroying contamination: bonfires, burning sulphur, burning clothes and bedding, washing surfaces with lime or vinegar, killing or removing urban animals. Such actions were predicated on an understanding that the disease moved from place to place through some medium or media, possibly involving, though probably not limited to, person-to-person contact. But while the eclecticism of this response is certainly indicative of uncertainty about how plague spread, the actions do show a responsive civil authority (Cipolla 1979, 1992). Indeed, in some ways plague prevention initiatives were themselves a means of state growth. Plague control required officials to oversee quarantine or isolation procedures. It required a staff to disinfect, and a structure to gather information on health conditions in remote ends of the state. An embassy, which in the high Middle Ages signified an official visit by one state to another, became in the Italian city states the permanent presence of one state in the territory of another. Its initial purpose was to monitor the public health in the host country and to send word home if plague broke out (Cipolla 1981; Slack 1985).
The patterns and practices of the plague form the core of the catalogue of public responses to later epidemics of other diseases—flight, the exacerbation of social tensions leading to scapegoating, a heightening of religious seriousness (often combined with a collapse of normal customs and obligations), and a mix of pragmatic efforts to disinfect people, places, goods, or the environment, and to isolate victims or potentially contagious strangers (Briggs 1961). The particular mix of these actions reflected the current state of debate between proponents of atmospheric theories, including miasmatic theories, which located the origins of the epidemic in some unusual state of air, and of contagionist theories, which emphasized various forms of interpersonal transmission, and presumed that epidemics could spread only as far as infected humans (or human products) carried them (Ackerknecht 1948).
Thus, in the nineteenth century the series of cholera pandemics which arrived in Europe in the early 1830s brought forth accusations by the poor that the rich were poisoning them (particularly the doctors who wanted their bodies for teaching and research), and by the rich that the poor wantonly persisted in living in disease-nurturing squalor. It also engendered calls for public fasts, pure living, and declamations against sinful society, and a variety of attempts to disinfect, quarantine, and isolate (Briggs 1961; Rosenberg 1962; McGrew 1965; Durey 1979; Delaporte 1986; Richardson 1988; Evans 1990; Snowden 1995). In nineteenth-century America, the response to yellow fever and malaria was regular flight and the abandonment of cities during the summer by those who could afford to do so (Ellis 1992; Humphreys 1992). The summer home, in cooler, cleaner, and higher ground, became a mark of upper-middle-class life.
Significant new elements of that pattern entered in connection with efforts to control epidemics of three other diseases: venereal diseases, particularly syphilis, smallpox, and a mix of diseases including typhus, typhoid, and relapsing fever that was known as continued fever.
Whether syphilis came to Europe from America or Africa, or had been present in Europe in milder form (perhaps labelled as leprosy), is a question that has been much debated. What is clear is that a virulent epidemic known often as the French disease or pox began to spread quickly in the last years of the fifteenth century, and can be traced to the intercourse between Italian prostitutes and French and Spanish soldiers during the siege of Naples in 1494. The connection of the disease with sex was made quickly, partly because of the initial symptoms on the external genitalia—the more expressive German term lustseuche had been adopted by 1510. As had not been the case with plague or leprosy, syphilis represented a serious epidemic disease that constituted a state problem, particularly because it affected military strength, but which was not susceptible to large-scale public action. It was further complicated by having variable symptoms and effects, having a long course during parts of which it was not clearly manifest, and varying in contagiousness and virulence. If syphilis was to be controlled, states must prevail on individuals to avoid behaviours that spread the disease. One might expect that the moral opprobrium that went with contracting a disease that was usually acquired through illicit sexual contact to have had some role in discouraging such practices, but it did not. For an adventurous young man, a case of pox was a cost of doing business, even a badge of achievement. The disease was deemed curable, chiefly through mercurial treatments. While there are suggestions that by the eighteenth century syphilis had become something to hide (though not necessarily for moral reasons), such was not the case during the sixteenth century, when the disease was spreading rapidly (Arrizabalaga 1993; Arrizabalaga et al. 1997).
State attention shifted from cure to prevention only in the eighteenth century, partly because syphilis was becoming more clearly distinguished from other venereal conditions and as the varied phenomena of tertiary syphilis were becoming more evident. While the European states varied significantly in the priority they put on syphilis as a public problem, their approaches did not vary greatly: the disease was to be controlled by regulating prostitutes, who were regarded as the reservoir that maintained the contagion. Such approaches may well have had a significant effect in controlling the disease, but they exposed tensions between state and individual rights that have since become common in public health. Such conflicts developed first in the United Kingdom following the first Contagious Diseases Act of 1862, even though its programme against venereal disease was much smaller than that of France, where prostitution regulation was a central feature of public hygiene. The British Act allowed the police in designated garrison towns to arrest and inspect women presumed to be prostitutes and to confine infected women in hospital. It led to a sustained campaign for repeal that was ultimately successful in 1885. The repealers represented a broad coalition. Some objected that the legislation was morally indefensible because it acquiesced in the immoral industry of prostitution, others that it singled out women as responsible for a problem that was as much the responsibility of the men who used the services of prostitutes, while still others objected that the practice of arresting women was arbitrary (except with respect to class) and stigmatized working-class women who were not prostitutes (Walkowitz 1980; McHugh 1982).
The problem that the British parliament faced stemmed from liberal principles of human rights. Ironically, the Contagious Diseases Acts had been touted as respecting rights—the rights of men: the state would inspect women because male soldiers and sailors would not put up with genital inspection. Nor should they be expected to in a state in which the male franchise was broadening and the public was becoming increasingly uneasy with declarations that part of its population existed as cannon fodder. But recognizing the rights of men simply made it all the more clear that they were not accorded to women.
The issues that arose in combating venereal diseases arose in a more general way with regard to smallpox. While the ninth-century doctor Al-Razi had viewed smallpox as a normal childhood condition, a particularly dangerous part of growing up, it had become more virulent in fifteenth and sixteenth century Europe (Clendening 1942). By the eighteenth century it was accounting for 10 to 15 per cent of deaths. It was then widely recognized as a contagious disease of childhood, one sufficiently deadly that many parents exposed young children to it if it were present. Sooner or later one would be exposed—the older child who died from it was a time investment lost; the younger one who survived was subsequently immune. Accordingly, the practice arose in many parts of the world to induce smallpox. Whilst folk therapeutics owed nothing to medical statistics, it was recognized that some means of inducing the disease made it significantly less virulent. Mortality rates of 25 per cent or more might drop to a few per cent. Notwithstanding assertions that such practice defied providence, and its inherently counterintuitive character, such logic and experience had much to do with the relatively rapid acceptance of inoculation after 1721, when it was introduced into Western Europe by Lady Mary Wortley Montagu, a particularly ell-connected aristocrat, who had observed the process in Turkey. It was taken up first in the British Isles; its subsequent spread elsewhere depended on the patronage of royalty and nobility, on increases in the safety of the procedure, especially when carried out by the most highly skilled practitioners, and the acquiescence of at least a segment of the medical profession (Miller 1957; Razell 1977; Hopkins 1983).
In 1798 the English practitioner Edward Jenner made immunization significantly safer by introducing the practice of vaccination with cowpox. Increasingly, smallpox prevention, which had hitherto been a personal matter, became a state concern. Presumably, the institutions that orchestrated quarantines could also ensure universal vaccination. But here too there was ambiguity: in whose interests were vaccination programmes to be undertaken? England began offering free vaccination in 1840, made it compulsory in 1853, and instituted fines for non-compliance in 1873. The initial assumption that all would take advantage of this free medical service proved unfounded; as the authorities sought to give the vaccination laws more teeth, they encountered growing opposition and decreasing rates of compliance. In 1898 antivaccinationists achieved permission for conscientious objectors to forego having their children vaccinated. The opposition was able to show that the dangerous procedure was not carried out everywhere with sufficient skill or care; and a real decline in smallpox meant decreasing risk to the unvaccinated. But mandatory vaccination also exposed underlying tension between the state and the public: in an atmosphere of distrust of the state, the more insistent the state became, the more convinced became the public that the state’s actions were not in its interests (Porter and Porter 1988; Baldwin 1999; Brunton, in press).
It is important to emphasize that for most of the history of the West, efforts to combat epidemic disease had not reflected any sense of obligation to the health of individuals. At stake was the military, commercial, and cultural welfare of the state; the welfare of individual subjects (a better term than ‘citizens’ for much of the period) was incidental. While states devoted substantial resources to enforcing quarantines and other health regulations (and absorbed considerable costs in lost commerce), it would be misleading to think of them acting in some quasi-contractual way as agents of groups of individuals who had recognized that public actions were necessary to secure their own health. Whilst many places had town or parish doctors, and while there was often an expectation that the state take steps to protect the welfare of its subjects (such as making food affordable in times of dearth), early modern political theorists recognized no obligation of the state to protect the health of individuals. What was at risk in an epidemic was the state itself: the collection of taxes, the maintenance of defence, the continuance of commerce, and even the orderly transfer of property at a time of high mortality.
Perhaps nowhere was the tension between individual and state so great as in the combating of what was called continued fever. Typhus, typhoid, relapsing fever, and yellow fever were amongst the several epidemic diseases that appeared or became increasingly prominent in the aftermath of the Black Death. This ‘continued fever’ was endemic as well as epidemic, and amidst vast disagreement about classification and cause, there was general agreement about its frequent association with social catastrophe and squalor


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